Basic Information
| Provider Information | |||||||||
| NPI: | 1700884137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRADDOCK | ||||||||
| FirstName: | DURRETT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 E GRAY ST | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025851735 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026297601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01058855A | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000308613 | 01 | KY | BC BS | OTHER | 50005977 | 01 | KY | PASSPORT | OTHER | 000000330651 | 01 | KY | BC BS | OTHER | 64054075 | 05 | KY | MEDICAID |